Countermeasures Injury Compensation Program (CICP)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 4.2 Death Benefit Certification of Relationship (Survivor Attach 2).docx	Form	Modified	Repair queued
Form 4.1 Certification of Status for Death Benefit - Standard Calculation (Attachment 1)	Form	Modified	Available
Form 3.4 Unreimbursed Medical Expenses Certification - Estate (Attachment 4)	Form	Modified	Available
Form 3.3 Lost Employment Income Certification - Estate (attatchment 3)	Form	Modified	Available
Form 3.2 Certification of Status for Death Benefit - Alternative Calculation (Attachment 2)	Form	Modified	Available
Form 1.3 Lost Employment Income Certification (Attach 3).docx	Form	Modified	Available
Form 1.2 Unreimbursed Medical Expenses Certification (Attach 2)	Form	Modified	Available
Form F Attachment F - Additional Documentation Form	Form	Modified	Available
Form E Attachment E - Authorization Form	Form and Instruction	Modified	Available
Form D Attachment D Request For Benefits Form	Form and Instruction	Modified	Available
0334 CICP Supporting Statement PASSBACK CLEAN.docx	Supporting Statement A	Uploaded 2017-01-24	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
208418	Benefits Package and Supporting Documentation	Form	Modified	Death Benefit Certification of Relationship (Survivor Attach 2).docx
208418	Benefits Package and Supporting Documentation	Form	Modified	Certification of Status for Death Benefit - Standard Calculation (Attachment 1)
208418	Benefits Package and Supporting Documentation	Form	Modified	Unreimbursed Medical Expenses Certification - Estate (Attachment 4)
208418	Benefits Package and Supporting Documentation	Form	Modified	Lost Employment Income Certification - Estate (attatchment 3)
208418	Benefits Package and Supporting Documentation	Form	Modified	Certification of Status for Death Benefit - Alternative Calculation (Attachment 2)
208418	Benefits Package and Supporting Documentation	Form	Modified	Lost Employment Income Certification (Attach 3).docx
208418	Benefits Package and Supporting Documentation	Form	Modified	Unreimbursed Medical Expenses Certification (Attach 2)
208418	Benefits Package and Supporting Documentation	Instruction	Modified
208417	Additional Documentation and Certification	Form	Modified	Attachment F - Additional Documentation Form
208416	Authorization for Use or Disclosure of Health Information Form	Form and Instruction	Modified	Attachment E - Authorization Form
208416	Authorization for Use or Disclosure of Health Information Form	Instruction	Modified
194529	Countermeasures Injury Compensation Program Request Package	Form and Instruction	Modified	Attachment D Request For Benefits Form

ICR Details

OMB Control No: 0915-0334	ICR Reference No: 201609-0915-001
Status: Historical Active	Previous ICR Reference No: 201308-0915-005
Agency/Subagency: HHS/HSA	Agency Tracking No: 20201
Title: Countermeasures Injury Compensation Program (CICP)
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 01/30/2017
Retrieve Notice of Action (NOA)	Date Received in OIRA: 09/16/2016
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2020	36 Months From Approved	01/31/2017
Responses	260	0	260
Time Burden (Hours)	1,327	0	1,327
Cost Burden (Dollars)	0	0	0

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Abstract: OMB approval of the information collection requirements for the Countermeasures Injury Compensation Program (CICP or Program). The CICP provides compensation to eligible individuals (requesters) who suffer serious injuries directly caused by a covered countermeasure administered or used pursuant to a PREP Act Declaration, or to their estates and/or survivors. The CICP requires the Request for Benefits Package, which includes the Request for Benefits Form and Authorization for Use or Disclosure of Health Information Form(s), as well as the injured countermeasure recipient’s medical records and supporting documentation to determine whether a requester is eligible for Program benefits (compensation) for their injury and if applicable, to calculate the amount of program benefits a requester is eligible for.

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Authorizing Statute(s): US Code: 42 USC 247d-6d Name of Law: Public Readiness and Emergency Preparedness Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 43215	07/01/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 60708	09/02/2016
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 4

table that charts list of burden

IC Title	Form No.	Form Name
Additional Documentation and Certification	F	Attachment F - Additional Documentation Form
Authorization for Use or Disclosure of Health Information Form	E	Attachment E - Authorization Form
Benefits Package and Supporting Documentation	1.2, 1.3, 3.2, 3.3, 3.4, 4.2, 4.1	Unreimbursed Medical Expenses Certification (Attach 2) ,   Lost Employment Income Certification (Attach 3).docx ,   Certification of Status for Death Benefit - Alternative Calculation (Attachment 2) ,   Lost Employment Income Certification - Estate (attatchment 3) ,   Unreimbursed Medical Expenses Certification - Estate (Attachment 4) ,   Certification of Status for Death Benefit - Standard Calculation (Attachment 1) ,   Death Benefit Certification of Relationship (Survivor Attach 2).docx
Countermeasures Injury Compensation Program Request Package	D	Attachment D Request For Benefits Form

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	260	260	0	0	0	0
Annual Time Burden (Hours)	1,327	1,327	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $1,443,678

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 09/16/2016

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